ruunndqnBing Tones mefinoemanigndy fnsunnumand wine deniuns ina gaslnssataa (uit jus imag) CAS No. 74d0-46-2 UN No. 1407 ! dodu doyavialuvosarneil {O91 Caesium-137 Cesium-137 hulamsdowinn anositu yavaeunat 28.5 outendes Cuvoumeriiqangivies usitnas Jum funsolsdnewuuasaiin udau¥vfiumwacunaal Available uses/form/source + flogidntiodlufoamr199Uls4 (Geiger-Mueller counter) + ufasdomensunndliinwusiia sanasanseuatiluvisinlélulsor + Winmaumumvosdarineg wu nsenry wiulens sMlatuvosufiiedantuswulavilulss + sawn inmannaesseidn Health Effect (Acute Exposure) and management oivnimw sLocal effect: Rawils «systemic effect: sevuifen maiuowne nguornraduunduarnivd (A ARS aeifituldfasitony toil 1, Viannnidtidositouingsno Aodintowiy 0.7 ust (Gray) wie 70 used (rads) 2. uvdiefanvestediDuernmewen 3, Havindutoutuuuutineqnends 4. 5 armnestiemutfioutione wfortmuele Sedhiomunldgnudoveontunenduy douluaiduurt 3.nguainis 210 ARS 1. nguoannsnalunszgn (sruuifion) nlAdsuslmused 0.3 Gray woo 30 rads urtiniternstinew flolétiv 0.7 Gray w8o 70 rads ovmnaunill ¢ svew seueusn (Prodromal stage): auld oruu Weorws Guilornrsbddous 1 Falusde 2 arnrntuldunabuanigeneneg Au seueaos (Latent stage): wodfurudetulunsegnmel iiruoroqunivichiiowns seuvaru (Manifest iliness stage: Gears Tt doumdu Vanna emunanseduasdoug luna maresalani uaeetteFolunm 2-3 dow gireainde*inain misfintelunseuaaon vi fuvddlauted 4 seueteniuediiud auavtusnds 6 Alani inion UinBonunsuexinsnidon afoneonwinuar liaise lh 12suv fluila (Recovery): *ilrudnilugjsemusinaviefansegnlounn Tnusetiulmarndaue 2-3 Auer a 2.0 GWrusranfentlooeiduting 60 Au mnlaSuRd 25-5 Gray ~ LD gogo = 25-5 Gray) 2. nduornsmaiauorwns (Gastrointestinal syndrome) Winernlaudiaiiu 10 Gray (aoutiouthildatusl 6 Gray) Sioudaulugiindetioly 2 Aue sinmafiseuy anaduetmsuaelunsegeimuvhauunebiararsodouuenll seazusn (Prodromal stage): nduld awiuu ears vinvies Neudy Guflernrsmelu 2-3 flus islnuisa 2409 (Latent stage): wadiiurnidelilunseqnuasidoymaduormmeludesy worth vichillowns ssuviiveliiu 1 dua seevanu (Manifest illness stage): Woowns it downdy Howdy vim infowisreg Anund andetin Tuner 2 Adm vinarsfinde wimb indouseuni svoviluda (Recovery): utimiomuawrniléSaaiiu 10 Gray (LO 100 = 10 Gray) 3, nuornismaseuutalonaonifonvfoseuuusein iinlnudtd > 50 Gray (UraAU > 20 Gray) seevtisn (Prodromal stage! junnclitooghh rfuildoreusheunmedsann filial Aalunenouunh seuvaen (Latent stage nétaniieanwunild waitalltalus seetvary (Manifest illness stage): owsuuvioseunnginngs daufuiitn Tria sinvfinnrelu 5-6 Galas wddlouihd uswtindenlu 3 Au seaviluda (Recovery): tail nguonnasAuflawifeaindel (Cutaneous Radiation Syndrome) ahifamnmsvudoumstialundsaitoniatoder viouilauded setfinnsdniay ure Snasmaaaen saxfowusengady oinrunsvedtantiteraRalitius 2-3 dhlundilauisd wero adhgdrstmamtagroutaedna nntiufinesnduanuntuanng 8n dautuliqnhuaeunaéniay (ulcer) osnoneasiitu Veer lugiemiademe mvs du ronwelnuvhiaw Aovtieme Siosdhiaude’s vinitln voArwvo nansemussexen) usagi masreil 2 Usanunriaianudesnnondaenylanon inisiisihisliaotinlaemmsiuha seuniedu Sutedhinin seucaadue | mnmiusnnondrorgluvionsiinusatialhdetinlh lrads (Gray) snnmraaiatevaanedun® 10001) 08 100 (0) 8 200 (2) 6 300.3) 248 600.6) >40e 1,000 (10) 350° saneun: a - seernmdivanetiomsdutat fame daefinranliuiatedy, bb - prrnudusnaondaserlesion afinueiéeflaldsfino nm adutiiealieannutouay 24; weed ula adivenetud undu uetisuingontnee tended 5 0 c~ Wau doofiaansnsensiolaernnraen sinus {uuu (acute radiation syndrome)misquarioudstsenuavna 1 wneud wédern stabilize Aud wendseutunratuiavtonauudlounsfialuads | , F 5 Ureuiumsuidoumeuonuavaciiniislu ua iSouyngelu record form | eee ee ee Ae phafliiuia viet udouaratiahunis Viguadommumduieetauitinion | finn 2 3 4. shonssaedhednamudhlay a1 qaufinung 5 a ee a! Voudnasalawtivetosoaunu vinulvihinisdid aysasny iviuetosoedlaseduned fli 2 wines background 6. firsanmadeiftaandudmmnfinsuyatoned ~ didisedranrsuuitlououldtiouns 2 wives background = finsvinidu wfofinasvnadtudintion = UauSeflalif 2 Gray 7. usitawrndiolationtieorn 3 doxwuy idanalusn, masiosfudantuamthil: PPE level D surgical mask aii latex Gown Adesiuastandsls wuerrwenrequsinw iilouitldluvosnivin msilosfunrsuudlouyiugd 1. wrlilinguindulAiuanwds wodnsuudoumstntundeasaudte 2. wnnlauiawesd (wiuiurmunrschunmienesd) Aloussaevlsifinsdutdos Wudlaidosfeatreelautatorniuraudendn (haderutinbinagquagtvhutludemmensiséi) 3. lunsdliig{uindulisvudloumsfntundsd Aodlanstuulunfetoguulawis doth wlomelusanw vos asihdvaoan uu! A Slomhimiseeds jauturiou houbimsinemto ( 3 Hadlinvsvauina juasdlu Al#Ineon (brush off) siniu AtVinondofiieon udrowih gfem] wos Hinfanrnn vdtorubiasatlvnsranouteindosmsre hada maasremmtoslg sins s asaanrsUuttouarsihulundvamelusranelaansaunugieda waste Widonseeanseands sate CBC yn 4-6 wails 2 du oma msedusindony avinaailvled Incl’ Andrews Lymphocyte nisfusiuadsa lunsdl juss uusifauuinugu riauhinaseedie) wudhi Nomogram / eat L BEASTS 14Andrews Lymphocyte Nomogram NORMAL a qt 1 Andrews Lymphocyte Nomogram From Andrews GA, Auxier JA, Lushbaugh CC. The iiosanire Importance of Dosimetty to the Medical Management of Persons Exposed to High Levels of Radiation. severe} INJURY In Personal Dosimetry for Radiation Accidents. wy Vienna : International Atomic Energy Agency; 1965 ine - #329 chromosome aberration cytogenetic bioassay mmeifgalumsUssiiNvianaATATY = 9929 serum electrolyte WAY hemoculture mruteuedmrsrain msinwn Acute Radiation Syndrome 1. Visine morn slufiazonn dutullélisuddaelilunedduiinuldlyl (ue Unit) 2. Vinraioatuusednwinisiintio 3. nsedunisvieuvasseuussen (hematopoiesis) lnunislv growth factor 4, Ugnsinetadiurtadin (stem cell) wiolvinnidon udauntousd 5. dhaannornsnasfiawnls wu was aan esas Boysneg diay (mucositis) Wh shudinan 6. Vinrsquavinuaele 7. Vanwideaoiytiusineg mindudu wu Aulsladin lafinde gterrgirudsatnwr Internal Contamination ynnwuh stool radiation bioassay nunrsuudowves cesium-137 melusramevosdilae Wsrewrte Prussian Blue oven cesium-137 finsge@ua inn amuomsludamuuaednrsduoonmahadaveitag misiiuawnsdnads myuauludees (entero-hepatic recirculation) nislii antidote Aa Prussian Blue seit cesium-137 Surtuard sauanfaneives cesium-137 Tustin eas Tnevisluuusrltht Prussian Blue wiu 30 Su anstiidunt wowwunhildtuiiuheet intemal contamination Snyfelsisinnransa stool radiation bioassay anne imuorevosifday dod = 3g PO tid x 30 days (flu) oy 18 duly) = 2.@ PO tid x 30 days (inorysewtns 12-18 t) - 1g PO tid x 30 days (Winerysewins 2-12 8) nvstiansaaiinnw (Follow up) - Wifthoamerdoutumbunuiiterios wu lsmenraiiiugdawossiemaues (erat) ~ Rnmavornnstuuwnd Inensaa CBC siediovedrnloetunentsainsioty 34u oimsiiaaswuunnd (ndandutu) = pdulfowdou showwemin unt 2 a¥s M8 muradu thonoontiladinds mslunthedurwhndslnusea voiinsduidouarstuatundaa = nin initnidonsrah TnesawnsAaiiles! ovsleud@annainn uavoreflonmsvinnslivAdeundy (Acute Radiation Syndrome) Wiindalsenuruia vViemheruiiuaaveudanqnisalnedia tonarsusznounisiuuies 1, READE. Cesium (Cs) metal / cesium liquid from READE (Cited 2013 Sep 23), Available from: bitpy/wnner roducts/16-element-substance-matter-chemical-inorganic-powder-sheet- 2. Wikipedia. Caesium, (Cited on 2013 Sep 23). Available from: httpy/en wikipedia. org/wiki/Caesium 3. Centers for Disease Control and Prevention. Emergency Preparedness and Response, (Cited 2013 Sep 23). Available from: httny/emergency.cdc.gov/radiation/ 4, US. Department of Health and Human Services. Radiation emergency medical management: guidance ‘on diagnosis and treatment for healthcare providers. (Cited 2013 Sep 23). Available from: ‘nttp/Aww.remm.nim.govUnunMuUIMensquadUiUIAdUTInN sauased / arsfudtunded Radiological or Nuclear Incident i ‘Check ABC and stabilize patient FIRST before managing radiation problems Assess external ~ Contact radiation Safety officer PF Lisstcnann n with radiation survey meter idence of Ex contamination Yel: Decontaminate patient externally Te Xe2: Re-sean patient with radiation survey meter Sdiation reading < 2 time? No imal or ne physical injury es Yes | Discharge home with scheduled follow-up and home observation instuetio No Adnvt to hospital background 0 I I Evaluate for acute radiation syndrome Treat physical injury, if any Repeat X-1 and X.2, but mere than 2n y re atte (8s) (Check for internal contamination + Swab each nostri separately to helo ‘estimate (evel of intemal (Lung) ‘contamination = Collect urine » 70 ml and stool for isotope measurement Estimate dose of radiation from 1. Lymphooy 2.Time to onset 3. Praomal symptoms 4, Chromosome analysis (dicentrics) 1 ¥ ‘Administer antidote based on isotope identtied (Cesiur-137 vs ledine-13: vs Cobalt-60} Manage ARS andi burn * Calculators ae avaliable at htipy/mmerremm. im gou/ars_ woe htmivomit ™ Use Andrew's Lymphocyte Nomogram nus WIBUTOrder for Cecium - 137 Poisoning Rayong Hospital Progress Note | Date/ Order for one day Date Order for Time Time | continue Dad Precaution at 1 Infections = Contact, caplet, 1D Radiation bioassay 1 a (intemal contamination suspected) iscaion/netrpenic - collect spot urine > 70 ml 2, Radiation precaution (if external and/or Cy Radiation binassay 2 intemal contamina (if internal contamination suspected) stitL exist) = Stoot collection =Single 129m, go¥n, Di cac 46 hours me Oi Serum electrolyte 4 = Pace Racaton Stety 0a, Mi, POS « hous Sian on door Or Blood Sugar “recent sett ne Oeune. = Over room = must wear Diateadece 0 Trop-T, ckma personal radiation CpveriaNe other ama = Use mecical fay eee procedures for dis- Dichest xray Cl Pataterat posal of radiation O Portable waste Recon: ‘TREATMENT OWS 2 hours x 4 1 0.996 NSS 1000 ml. CHp.nanurV/ar Cvs qahous x4 1 59% DINSS/2 1000 ml. dep.auml/he Os ward routine Notify physician for: 1D other uid ee alood bank 69> 180, <100 Di type and cross match 50 3209, «50 Type and screen Boies For _ units of packed red blood cells eee For units of platelets Department of service| Ward Physician Name of patient Age HN CARAS TRY 18Order for Cecium-137 Poisoning Rayong Hospital Progress Note | Date/ Order for one day Date Order for | Time ‘Time continue | Day2 Respiratory Therapy: an Use radiation ore caution for personel, C1 Radiation bioassay 1 equipment, and waste (if internal contamination suspected) if patient has intemal = collect spot urine > 70 mt ractaten contsvinaion Doom air 1 Radiation bioassay 2 Sook eo (if intemal contamination suspected) pects) = Stool collection Tate ongen 0 CBC wilt 4 6 hows we oe supplementation for 11 Serum electrolyte q OI_ hous Oaygen saturation came, Podq = _hours > ; nebulizer treatment our Dauner. coe (peat ‘TREATMENT 11 0.996 NSS 1000 ml. dipenumV¢he Wound cae: 1 58% B/NSS/2 1000 mL. dipionnamUVDr SB ecortamiate O other fluid : there is external sterile dressing to wounds dally For radiation-induced N/V: 11 Ondansetron 4 mg IV q 8h PRN for end TD monitor waste C1 Lorazepam 0.5 mg -1 mg PO q6-8h Buse mecieal facitty PRN for anxiely/insomnia/breakthrough proesdutes od discarding us) biological/radioactives For diarrhea: physical waste and 1 Loperamide hyckochlorde & mg (2 capsules) inens/towels/trash/ sonal protective stat followed by 2 mg (teapsule) after ‘each unformed stool. [not exceed 16 me/day For pain: CI Morphine sulohate __ me route g pours Department of service| Ward Name of patient Age 20 L CARAS TRYOrder for Cecium-137 Poisoning Rayong Hospital } Progress Note | Date/ Time Order for one day Date Sime Order for continue Day LAB Ti Raciation bioassay 1 (if internal contamination suspected) - collect spot urine > 70 mt Radiation bioassay 2 (if internal contamination suspected) + Stool collection Ocac O serum electrolyte ua ouc Owe HLA typing (i stem cell implant needed) Serologies: Ci Herpes Simplex Virus type 1 (HSV D Herpes Simplex Virus type 2 (HSV-2) 1 cytomegatovins (CMW) C1 aricelta-zoster virus WZV) TREATMENT 0.996 NSS 1000 ml, drp.nusmVhe 5% D/NSS/ C other fui 100 mil. drip......mVhr Silver Sulfadiazine cream topically to bums Ti Bacivach topiealy to bums Ci other wound management per Gun teamyDermatology/ Surges For rash Topical ster dressing Oi Hycroxyzine 10 mg PO a 6-8 hours for prortus For fever: C1 Paracetarnch__mg PO 46h PAN temperature> 38 °C For oral mucositis: Mouth care regimen Neutropenia therapy: if neutrophils + bands SF or filgrastim 1506 wo? g/day) -ovimicroials for neste see footnate below) * Neutropenia with NO F: 400 mg POAY dally Standing Order: Cesium-137 VER: Levofloxacin 500 mg PONV daly 4/: Acyclovir 490 mg PO gi2h +/- Fluconazole IW qlh for two doses, then 4 mg/kg WV q12h *- Neutropenia with FEVER: ist2811 Cefepime 25m Wg 8h 4/- Vancomycin Lem IV q 12h 4/- Voriconazole éme/k Department of service| Ward Physician Name of patient Age HN nus WIBUTNAME. Doctor Treatment Record for Radiation Injury History of Present Illness: Past Medical History: History of Tetanus immunization: - Complete; last shot was: , = Incomplete or unknown Allergies: = Food: (specify) ~ Medications: (specify) = Others: (specify) Physical Examination WS! BP seonesPAMHG, PR von in, RR 02 Sat oe 96 (ON FIO, ), BT C (GA: cyanosis, dyspnea, tachypnea, NORMAL () EYE: conjunctivitis, corneal burn, NORMAL () Resp: abnormal breath sound. , Normal (Cvs: () Skin: skin Cherry red to light red, Bright pink, Bullae, NORMAL (1 CNS: headache, nausea, dizziness, convulsion, coma (} Other System or Associated injuries Site(s) of radioactive material contamination or burn Investigations: Management